Student Support Services TRIO
Income Verification
Name:
First M.I. Last Former Names/Maiden Name
Address:
Number & Street City State Zip
Telephone: ( ) Email:
Home or Message Number
SS#: Student ID # DOB:
MM/DD/YYYY
Number of dependents (DO NOT count yourself):
Did anyone else claim you on this year’s taxes? Y N
If YES, state individual’s name and relationship to you:
ATTENTION: you are required to provide a copy of the federal tax return in which you are listed
as a dependent. Obtain a copy from the individual you listed above.
If NO, read and sign the following statement:
I hereby certify that no federal or state income tax return has
been or will be filed for the year.
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List all sources of income and benefits you (and/or your spouse) received during the year specified
above. Do not include any financial aid.
Social Security Benefits/SSI/SSDI $ /month x months = $ /year
Child Support $ /month x months = $ /year
SBAP/TANF $ /month x months = $ /year
Veterans’ Benefits (any type) $ /month x months = $ /year
Workers’ Compensation $ /month x months = $ /year
Other $ /month x months = $ /year
The information provided on this form is correct and complete to the best of my knowledge.
Student’s Signature: Date:
Updated: 8/12/2015 The SSS TRIO program is 100% federally funded.
